Case 1

A central line was sited by an FY2 doctor supervised by a more senior resident doctor. The hospital protocol was followed, and the guidewire position was confirmed with ultrasound. A post procedure chest x-ray was reviewed by the more senior resident doctor, who confirmed positioning.  A further review of the chest x-ray the following day reported ‘slightly medial’ but acceptable positioning.  The Patient was transferred to a different hospital where the line was transduced, revealing an arterial trace.

Case 2

Following emergency laparotomy for small bowel obstruction a patient was admitted to the critical care unit for management of postoperative pneumonia and ileus. Central venous access for total parenteral nutrition was required. Standard procedures were followed for line insertion including use of ultrasound to check guidewire position before dilatation. On flushing the line arterial blood was seen which was confirmed by transducing. Advice was sought from the IR and vascular teams and a CT angiogram confirmed the line had passed through the vein wall and the tip was sitting in the carotid artery. The patient remained well and was transferred to another hospital for removal under the vascular team. Immediately after the procedure the patient developed weakness and a facial droop. CT scan revealed a middle cerebral artery stroke.

Case 3

A patient was anaesthetised for liver resection for which an arterial line was inserted into the left radial artery. The operation was technically difficult and excessive  blood loss necessitated cardiovascular support peri and postoperatively with IV vasoactive drugs. The arterial line was found not to be working when the patient was in recovery. It was left in situ despite instructions to remove it. A few hours later it was noted that the patient's fingers looked ischaemic. The line was removed and a vascular opinion sought. Dry gangrene developed in the tips of two of the patient’s fingers. The patient subsequently attended ED due to pain and concern the ischaemia had started spreading.

Commentary

As illustrated by case 1, chest x-ray should not be used to confirm the correct position of a central line. It should only be used in these circumstances to exclude pneumothorax or confirm malposition.

Digital ischaemia as described in case 3, is a rare complication of radial arterial cannulation.¹ It is thought to be caused by distal embolization from an arterial thrombus at the site of cannulation. Although arterial cannulation to enable continuous cardiovascular monitoring may well be indicated, the line should be continuously irrigated, hypotension avoided and the line removed as soon as possible.

The Association of Anaesthetists will shortly be publishing an update to their 2016  Safe vascular access guidance.² It will recommend that a ‘scouting’ ultrasound should take place immediately before the procedure using sterile ultrasound gel. The insertion should then be done under real-time ultrasound imaging to identify the needle tip entering the vein and then to confirm, as far as possible that the wire is intravenous and not transfixing any other vessels before dilation takes place. ³ Case 2 illustrates however, that ultrasound visualisation does not always exclude inadvertent arterial placement. Transducers should be used to confirm venous placement once the line is secure.

1. Sfeir R et al. Ischaemia of the hand after radial artery monitoring. Cardiovasc Surg. 1996 Aug;4(4):456-8.
2. Association of Anaesthetists of Great Britain and Ireland. Safe vascular access Anaesthesia 2016; 71: 573-585.
3. Association of Anaesthetists. Safe vascular access. 2025. In Press.